Provider First Line Business Practice Location Address:
2300 W CAPITAL AVE
Provider Second Line Business Practice Location Address:
RM 109
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-2003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-385-6252
Provider Business Practice Location Address Fax Number:
308-385-6257
Provider Enumeration Date:
03/08/2007